The Alliance of Wound Care Stakeholders Outlines How Wound Care May Be Affected by CMS CY 2021 Hospital Outpatient and Physician Fee Schedule Proposed Rules

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August 13, 2020 – The Center for Medicare and Medicaid Services this week released for comment its proposed CY 2021 updates to the Hospital Outpatient Prospective Payment System and Physician Fee Schedule. Below are several provisions the Alliance has identified as particularly impacting wound care clinicians, which the Alliance will be tracking and preparing comment on.

The Alliance will be vetting these and other provisions with members in preparation of comment submission both to support select provisions and provide recommendations for change on other provisions. For all stakeholders, the deadline to submit comments is Oct. 5, 2020.

Physician Fee Schedule:

1. Telehealth:
The proposed rule includes a number of important telehealth policy proposals, including expansion of the list of telehealth services that will remain covered beyond the COVID-19 public health emergency.

2. Payment cuts for surgery:
CMS has proposed to cut payments for surgery, including proposed cuts in payment by 7% for vascular surgery and 7% for general surgery for CY2021.

3. Quality Payment Program
As clinicians across the country continue to respond to COVID-19, CMS is providing a delayed implementation timeline for the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) until the 2022 performance period. The Agency introduced an Alternative Payment Model Performance Pathway to align with the MVP framework.

4. Evaluation & Management:
CMS is revising a 2019 plan to pay a blended rate for level 2-4 visits, CMS will implement revised E/M code definitions developed by the AMA CPT Editorial Panel starting Jan. 1, 2021. The proposal to adopt revised coding definitions is paired with a decision to pay for each level of service rather than use a blended rate. CMS also proposes to adopt revised and increased work RVUs for E/M services based on recommendations from the AMA Relative Value Scale Update Committee (RUC).

5. CPT and HCPCS Codes
The proposed rule creates new E/M CPT and HCPCS codes based on the methodology used to assign beneficiaries to ACOs to reflect services for cognitive impairment and chronic management.

Hospital Outpatient Prospective Payment System:

1. Payment Methodology for Cellular or Tissue-based Products for Wounds (CTPs)
Over the course of the past few years, CMS has attempted to address the payment for CTPs in the hospital outpatient and ASC settings. In the CY 2019 proposed OPPS rule, CMS solicited feedback on four possible payment methodologies moving forward; in CY 2020 rulemaking, the Agency sought additional feedback on these options. (The Alliance provided comments and has met with CMS staff to share their feedback.) In the CY 2021 proposed rule, CMS did not propose any new payment methodology changes – so the current system will remain for CY 2021.

2. Payment Threshold for CTPs
The proposed CY 2021 MUC threshold is $47 per cm2 (rounded to the nearest $1) and the proposed CY 2021 PDC threshold is $936 (rounded to the nearest $1).

3. HCPCS Codes for Wound Care Products
CMS sought comments on the 100+ new codes it published in July 2020, including 25 that are relevant to wound care. A new “synthetic skin substitute” (CTP) code was proposed and placed in the high cost category.

4. Site-Neutral Payment
CMS will continue the CY 2019 policy of paying for outpatient clinic visits (HCPCS code G0463) when furnished in excepted off-campus Provider Based Departments (PBD) at 40 percent of the OPPS payment rate. A recent federal Court of Appeals decision upheld CMS’ authority to cut payments for clinic visits at excepted, off-campus PBDs.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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